Provider Demographics
NPI:1194985366
Name:GRESHAM, KIRK RICHARD (RN, LMFT)
Entity type:Individual
Prefix:MR
First Name:KIRK
Middle Name:RICHARD
Last Name:GRESHAM
Suffix:
Gender:M
Credentials:RN, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1206 WATER ST
Mailing Address - Street 2:
Mailing Address - City:PORT TOWNSEND
Mailing Address - State:WA
Mailing Address - Zip Code:98368-6725
Mailing Address - Country:US
Mailing Address - Phone:360-379-0911
Mailing Address - Fax:
Practice Address - Street 1:1206 WATER ST
Practice Address - Street 2:
Practice Address - City:PORT TOWNSEND
Practice Address - State:WA
Practice Address - Zip Code:98368-6725
Practice Address - Country:US
Practice Address - Phone:360-379-0911
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-11
Last Update Date:2008-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALF00001440106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist